Minnesota

A Minnesota program is aiming to tap the unused potential of international medical graduates who live in the state but can’t practice there.

The , housed in the Minnesota Department of Health’s Office of Rural Health and Primary Care (ORHPC), evolved out of a nonprofit established by Yende Anderson, IMG Assistance Program Coordinator, and her parents more than ten years ago, while Anderson was in law school. “We noticed there were a lot of resources for immigrants in Minnesota already, but it was mostly for those who were low skilled,” Anderson said. “We saw that doctors in particular have significant barriers.”

It was while advocating for IMGs at the state legislature that Anderson met Mark Schoenbaum (then-director of ORHPC), who agreed to take on an IMG task force. As a result of the task force’s recommendations, the Minnesota Legislature established the IMG Assistance Program in 2015, and ORHPC selected Anderson to be its coordinator.

According to Anderson, the IMG Program is of special importance to Minnesota because the state is experiencing “a perfect storm” of a projected shortage of physicians along with an aging physician population. It would seem that employing IMGs who reside in the state to work in rural and underserved areas would be an easy solution to the problem, but it’s not that simple, Anderson explained. Even if someone has graduated from a medical school that is recognized in the United States or by the World Health Organization, they must pass a two-step licensing exam and complete U.S. medical residency, even if they’ve completed a residency elsewhere.

“This residency piece is where the barrier is,” Anderson said. “There’s not enough money for U.S. graduates to complete residency, so when you add international medical graduates, there’s even more demand for the available supply.” The cost of a residency runs around $150,000 per year per resident, she said.

In addition to limited residency positions, most IMGs also lack U.S. clinical experience, a prerequisite for residency. “One of the legitimate concerns we learned from the task force is that IMGs aren’t always familiar with the U.S. method of practicing medicine,” Anderson said. “It’s a team approach with the patients as well as the other physicians. They really need an opportunity to be in a clinic and become familiar with U.S. medical culture.” The IMG Assistance Program now offers clinical experience through a partnership with the University of Minnesota.

The cause of IMGs is personal for Anderson because her mother was an IMG who was never able to practice in the states. “My mom didn’t complete her residency in Canada (which would have allowed her to practice in the states) but went back home to Liberia to help,” Anderson said. But after she returned, her father, William R. Tolbert Jr., who was president of Liberia, was assassinated during a coup d’état, and the rest of the family was persecuted. Like many others, her mother fled her home country for the United States. In order to remain here, she had to maintain a student visa, so she studied Epidemiology at the University of Minnesota for seven years, despite having a Master’s in tropical medicine from the London School of Hygiene and Tropical Medicine.

By the time her mother finished her program, she had been out of medical school for over 20 years, too late to apply for a residency since most residency programs require that physicians have graduated within five years of application.

Minnesota stands out as the first state to implement a comprehensive program to integrate IMGs into the physician workforce, although at least three other states are in the process of planning a similar program, Anderson said. “We get calls from all over the country and we are happy to offer technical assistance.”

The IMG Assistance Program receives $1 million of state funding each year, with more than half of it going toward funding residencies, Anderson said. IMGs who accept a residency position funded by the program are required to pay $15,000 or ten percent of their annual salaries into a revolving account for five years, beginning in the second year of post-residency employment.

The program also is researching another pathway to licensing, called a skilled pathway, which is being done in Canada, Germany, and Australia as a national program that targets immigrant doctors. “IMGs complete a skills assessment and an exam and if they demonstrate competency, they’re able to practice medicine without completing a residency program,” Anderson said. “In Minnesota we run into issues of credentialing and insurance reimbursement that require board eligibility (which itself requires completing a residency program). So, we want to continue to investigate that route and figure out if this is a possibility.”

“This work is a wonderful example of collaboration,” said Teryl Eisinger, Executive Director, National Organization of State Offices of Rural Health. “A nonprofit organization with a mission to serve IMGs met up with a State Office of Rural Health (SORH) with policy expertise and together they’ve built an innovative program in the SORH to address workforce needs in rural areas.”

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The future just got healthier for millions of Minnesotans, thanks to being one of seven states to receive a $45 million State Innovation Model (SIM) testing grant through the Center for Medicare and Medicaid Innovation (CMMI). “We are very excited to receive this grant,” said Mark Schoenbaum, Director of the Minnesota Office of Rural Health and Primary Care. “It’s a great opportunity for rural communities to get new support and build on the kinds of innovations that already take place in rural areas.”

The grant was awarded to Minnesota in February 2013 and will be used over a three year period ending in October 2016. The grant will be used to test new ways of delivering and paying for health care using the Minnesota Accountable Health Model framework. The goal of this model is to improve health in both rural and urban communities, provide better care, and lower health care costs. Up to three million Minnesota residents are expected to receive care through this model over the three year period.

“The grant component the Office of Rural Health and Primary Care is most directly involved in is the emerging professions project, which we administer,” Schoenbaum said. “Funds have been made available for a rapid expansion of emerging professions like community health workers, community paramedics and dental therapists. We expect over the next couple years, that rural Minnesota will see more professionals working in these fields.”

Funds will also be used to bring additional state certified healthcare homes to rural areas. “We currently have more than 300 state certified healthcare homes in both rural and urban areas of our state. Through the grant, that model will spread even farther and reach more rural Minnesota practices,” Schoenbaum said. “The grant will be used statewide, in rural and urban areas. Every community is unique and the grant is supporting solutions that fit each area’s characteristics.”

Mark Schoenbaum is the director of the Minnesota Office of Rural Health and Primary Care, a position he has held since 2005. He has been with the MN SORH since 1996.

What are the most significant things you’ve done with and for NOSORH–and how has it helped you as a SORH director?

It’s tough to narrow it down. Two themes that come to mind are:

· Watching and being part of NOSORH’s growth and development into a leading national organization has helped inspire me to be entrepreneurial in my state office.

· NOSORH has given me the opportunity to get experience analyzing national health policy issues, and that has helped me better understand and contribute to policy discussions in my state.

What do you mean by being “entrepreneurial” in your Office?

In addition to learning from my colleagues around the country how to make the most effective use of the core state grants that we have available as SORHs, we are always looking for opportunities to add complementary activities to our work. In addition to being the PCO for our state, we have a portfolio of state workforce development programs, and manage the state’s trauma system and medical education subsidy. We’ve been inspired to keep our eyes open for such opportunities both by the entrepreneurial spirit of Teryl and the NOSORH Board leadership, and by our colleagues in other states who have been creative in expanding their reach.

How have you analyzed health policy with NOSORH–and how this was applied in your state?

I think my first policy activity with NOSORH was after passage of the 2003 Medicare Modernization Act. CMS published regulations and asked for comments. Since I had an interest in looking at these issues, I approached the NOSORH leadership at the time-and they encouraged me to draft something up. Those comments ended up being submitted by NOSORH. It whet my
appetite for joining the Policy Committee and continuing that kind of work. In addition to that committee, I’ve also rotated through the Executive Committee as NOSORH President-Elect, President and Past President, and have served on other committees including the Flex Committee.

NOSORH has certainly given me more than I have given it. I’d encourage everyone to get involved!